Neurology & Pain Management Coding Alert

Question: Our physician did an SI injection in the office without any image guidance as the C-arm was not functioning. Should I bill 20552 or 20610?

Minnesota Subscriber

Answer: Actually, neither code you mention is your best choice. 

CPT® added fluoroscopy to the code descriptor for 27096 (Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT] including arthrography when performed) in 2012. The following parenthetical note also goes with 27096: “If CT or fluoroscopy imaging is not performed, use 20552.” Therefore, it is no longer correct to use 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) when billing an SI injection without fluoroscopic guidance. Instead, you should submit 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) instead of 27096 or 20610 for the injection.